Contractor Safety Questionnaire Form printable pdf download

Contractor Safety Questionnaire

At Electric Boat, Safety is our # 1 priority. Electric Boat’s goal is to select suppliers of services

and/or material that share this same goal. As a potential supplier, you are requested to complete

the questionnaire below.

Employers who are required to maintain OSHA injury and illness records must complete this

entire form. Employers exempt from OSHA recordkeeping do not need to respond to questions

7 – 16.

Company Name ________________________________________________________________

Local Address _________________________________________________________________

Person completing questionnaire

Name (print) _____________________________________Title__________________________

Phone number __________________________ Email__________________________________

Purchase Requisition #________________________________Date_______________________

1) What type of work is your company proposing to perform at Electric Boat? _______________

______________________________________________________________________________

2) What is the primary function of your business?______________________________________

______________________________________________________________________________

3) Has your business experienced a work related fatality in the last three years?

________________

4) If you responded yes to the above, provide a brief description for each fatality._____________

______________________________________________________________________________

5) Did your company employ 10 or more people at any one time last year? _________________

6) Does your company presently employ 10 or more people? ____________________________

7) What is your company’s Standard Industrial Classification (SIC) code? __________________

8) What is your company’s North American Industrial Classification System (NAICS) code? ___

______________________________________________________________________________

9) What is your companies most recent year end Total Case Incident Rate (TCIR)? This rate

should be calculated from the data obtained from your companies most recent 300A form (posted

Feb. – April). See page two for instructions for calculating this rate. ______________________

10) What is your companies most recent year end Days Away from Work, Restricted Work

Activity and/or Job Transfer (DART) rate? This rate should also be calculated from the data

obtained from your companies most recent 300A form (posted Feb. – April). See page two for

instructions regarding calculating this rate. ___________________________________________

11) What is your company’s present TCIR? __________________________________________

12) What is your company’s present DART rate? ______________________________________

13) What is the most recent TCIR average for your industry as published by the Bureau of Labor

Statistics (BLS)? _______________________________________________________________

14) What is the most recent DART rate average for your industry as published by the BLS? ____

15) Does your company have written safety or health policies? ___________________________

16) If you responded yes to the above, Has your written safety and health program been

certified/approved by a 3

party (e.g. Occupational Health and Safety Assessment Series

(OHSAS) 18001, OSHA Voluntary Protection Program (VPP)? _______________________

Direct any questions to Bill Adams (401) 268-2221 (Quonset) or Don Peterson (860) 433-3352

(Groton)

Contractor Safety Questionnaire Form

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